Chronic Obstructive Pulmonary Disease in the Intensive Care Unit: Antibiotic Treatment of Severe Chronic Obstructive Pulmonary Disease Exacerbations

Abstract

Patients who suffer from chronic obstructive pulmonary disease (COPD) often experience deterioration of baseline respiratory symptoms, acute exacerbations of COPD (AECOPD), that become more frequent with disease progression. Based on symptom severity, approximately 20% of these patients will require hospitalization. The most common indicators for intensive care unit (ICU) admission have been found to be worsening or impending respiratory failure and hemodynamic instability. Bacterial and viral bronchial infections are the causative triggers in the majority of COPD exacerbations in the ICU, with a comprehensive assessment revealing them in 72% of cases. The distribution of bacterial pathogens involved in AECOPD requiring ICU admission show an increased incidence of gram-negative respiratory isolates, including Pseudomonas and Enterobacteriaceae spp., when compared with outpatient exacerbations. Evaluation of these patients requires careful attention to comorbid conditions. An effort to rapidly obtain lower respiratory samples for microbiological samples prior to initiation of antibiotics should be made as adequate samples can guide subsequent modifications of antibiotic treatment if the clinical response to empiric treatment is poor. Empiric antibiotic treatment should be promptly initiated in all patients with a major consideration for the choice being the presence of risk factors for Pseudomonas infection. Evaluation of clinical response at 48 to 72 hours is crucial, and total duration of antibiotics of 5 to 7 days should be adequate.

Respiratory Infection Triggering Severe Acute Exacerbations of Chronic Obstructive Pulmonary Disease

“…One-third of the respiratory infections we describe in this work were not microbiologically documented, and may reflect the high frequency of antibiotic use before admission to the ICU, around 60% in the study by Daubin et al 10 The viruses and bacteria identified in our study appear similar to those described in the literature, with the exception of a lower frequency of Enterobacteria (6.6%) and P. aeruginosa (2.8%). [16][17][18] In a previous study of infectious COPD exacerbations in the ICU, P. aeruginosa was found in 7% of exacerbations. 14 Geographic disparity and local ecology may explain these variations.…”

The use of antibiotics in the early stage of acute exacerbation of chronic obstructive pulmonary disease in patients without obvious signs of infection: a multicenter, randomized, parallel-controlled study

“…Sanjay et al showed that with an increase in the sputum volume, exacerbation with dyspnea, and sputum purulence (Jacobs et al, 2019), the absence of prompt antibiotic therapy can be detrimental for many patients with COPD exacerbations (Sethi and Aaron, 2020). Gupta et al (2020) reported that all COPD patients should be started on empirical antibiotic therapy immediately and that the presence of a Pseudomonas infection should mainly be considered. According to the results of an investigative study, the use of antibiotics for AECOPD patients with no obvious signs of infection is significantly greater than that recommended by the guidelines, although the current guidelines do not recommend antibiotic treatment in these patients (López-Campos et al, 2015).…”

“…Early antibiotic therapy for AECOPD patients with infection can effectively reduce short-term mortality, reduce the treatment failure rate, and improve sputum production (Gupta et al, 2020;Lancaster et al, 2020;Sethi and Aaron, 2020). Wang et al (2020) reported that there was no difference in the efficacies between antibiotics and placebo in AECOPD patients without infection (Roede et al, 2007), and there is no consensus on the use of antibiotics in AECOPD patients.…”

Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the ICU: An Observational Study From the OUTCOMEREA Database, 1997–2018

“…However, the systematic prescription of antibiotics remains controversial, as stated in the latest GOLD recommendations (1). For the ICU population, there is no clear recommendation for antibiotic use (19), and no validated biomarkers have been established to guide prescription (20, 21). Again, previous studies have frequently excluded patients in the ICU (22, 23).…”